338 VOL 55, NO 4 / APRIL 2006 THE JOURNAL OF FAMILY PRACTICE EVIDENCE - BASED ANSWER When are empiric antibiotics appropriate for urinary tract infection symptoms? ■ Evidence summary An evidence-based review 1 found 5 high- quality studies on the diagnosis of acute uncomplicated UTI among women. (“Uncomplicated” was defined as normal urinary tract and no contributing medical problems, such as diabetes, neurogenic bladder, renal stones.) UTIs were defined as the presence of significant bacteriuria (≥10 4 to 10 5 colony-forming units) on culture. A patient presenting to a clinician with 1 or more UTI symptoms had approximately a 50% chance of having significant bacteriuria on culture. 1 The authors estimated the pretest probability of UTI as 5% from the incidence of asymp- tomatic bacteriuria among healthy women. 1,2 This produced a LR+ of 19 sim- ply for presenting to a clinician with 1 or more UTI symptoms. 1 The summary LRs for clinical signs and symptoms in the pre- diction of UTI after presentation to the office are found in TABLE 2. A history of a vaginal discharge or irritation has a LR– of 0.3, decreasing the probability of UTI for a patient presenting to the office from approximately 50% to 20%, so further testing would be indicated. 1 Healthy, nonpregnant women presenting with the triad of frequency, dysuria, and no vaginal symptoms have about a 96% chance of having an urinary tract infection (UTI) (positive likelihood ratio [LR+]=24.6). Since no urinalysis result would substantially change the high likelihood of disease for these patients, empiric therapy is appropriate (strength of recommendation [SOR]: B). A triage system based only on having 1 or more urinary symptoms is more sensitive but less specific: the chance of having a UTI drops to 50% (LR+ =19). While empiric therapy is still likely to be appropriate, rates of false positives and inappropriate antibiotic use may rise (SOR: B). Empiric treatment by telephone may also be considered (SOR: C). While no studies have specifically addressed the diagnostic value of UTI symptoms reported by phone, no increase in pyelonephritis or other adverse events has been seen with telephone treatment protocols. And while telephone treatment protocols can increase the use of guideline-recommended antibiotics and decrease costs, they may increase unneces- sary antibiotic use overall. Contraindications to empiric therapy are listed in TABLE 1. Lauren DeAlleaume, MD, Elizabeth M. Tweed, BSN, MLIS University of Colorado Health Sciences Center, Denver CLINICAL COMMENTARY Telephone protocol for UTI reduces unnecessary office visits and lab testing We have 10 years of experience with a telephone treatment protocol we developed for uncomplicated UTI; it has since been adopted by the Institute for Clinical Systems Improvement (ICSI). The protocol reduces unnecessary office visits and lab testing. We believe the protocol actually increases our prescribing of preferred first-line antibiotics for UTI. While it is convenient for our patients, its use has resulted in patients wanting to be treated over the phone even if they have “failed” the protocol. Overall, our patients are thankful we have a telephone protocol for uncomplicated UTI. We enjoy the use of a handful of other telephone protocols and hope to move toward web-based protocols in the future. Robert Bonacci, MD Mayo Clinic, Rochester, Minn CONTINUED CLINICAL INQUIRIES Copyright ® Dowden Health Media For personal use only For mass reproduction, content licensing and permissions contact Dowden Health Media.
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338 VOL 55, NO 4 / APRIL 2006 THE JOURNAL OF FAMILY PRACTICE
E V I D E N C E - B A S E D A N S W E R
When are empiric antibiotics appropriate for urinary tract infection symptoms?
Evidence summary An evidence-based review1 found 5 high- quality studies on the diagnosis of acute uncomplicated UTI among women. (“Uncomplicated” was defined as normal urinary tract and no contributing medical problems, such as diabetes, neurogenic bladder, renal stones.) UTIs were defined as the presence of significant bacteriuria (≥104 to 105 colony-forming units) on culture. A patient presenting to a clinician with 1 or more UTI symptoms had approximately a 50% chance of having significant bacteriuria on culture.1 The
authors estimated the pretest probability of UTI as 5% from the incidence of asymp- tomatic bacteriuria among healthy women.1,2 This produced a LR+ of 19 sim- ply for presenting to a clinician with 1 or more UTI symptoms.1 The summary LRs for clinical signs and symptoms in the pre- diction of UTI after presentation to the office are found in TABLE 2. A history of a vaginal discharge or irritation has a LR– of 0.3, decreasing the probability of UTI for a patient presenting to the office from approximately 50% to 20%, so further testing would be indicated.1
Healthy, nonpregnant women presenting with the triad of frequency, dysuria, and no vaginal symptoms have about a 96% chance of having an urinary tract infection (UTI) (positive likelihood ratio [LR+]=24.6). Since no urinalysis result would substantially change the high likelihood of disease for these patients, empiric therapy is appropriate (strength of recommendation [SOR]: B).
A triage system based only on having 1 or more urinary symptoms is more sensitive but less specific: the chance of having a UTI drops to 50% (LR+ =19). While empiric therapy is still likely
to be appropriate, rates of false positives and inappropriate antibiotic use may rise (SOR: B).
Empiric treatment by telephone may also be considered (SOR: C). While no studies have specifically addressed the diagnostic value of UTI symptoms reported by phone, no increase in pyelonephritis or other adverse events has been seen with telephone treatment protocols. And while telephone treatment protocols can increase the use of guideline-recommended antibiotics and decrease costs, they may increase unneces- sary antibiotic use overall. Contraindications to empiric therapy are listed in TABLE 1.
Lauren DeAlleaume, MD, Elizabeth M. Tweed, BSN, MLIS University of Colorado Health Sciences Center, Denver
C L I N I C A L C O M M E N T A R Y
Telephone protocol for UTI reduces
unnecessary office visits and lab testing
We have 10 years of experience with a telephone treatment protocol we developed for uncomplicated UTI; it has since been adopted by the Institute for Clinical Systems Improvement (ICSI). The protocol reduces unnecessary office visits and lab testing. We believe the protocol actually increases our prescribing of preferred first-line antibiotics for UTI. While it is convenient
for our patients, its use has resulted in patients wanting to be treated over the phone even if they have “failed” the protocol. Overall, our patients are thankful we have a telephone protocol for uncomplicated UTI. We enjoy the use of a handful of other telephone protocols and hope to move toward web-based protocols in the future.
Robert Bonacci, MD Mayo Clinic, Rochester, Minn
C O N T I N U E D
CLINICAL INQUIRIES
Copyright® Dowden Health Media
For personal use only
For mass reproduction, content licensing and permissions contact Dowden Health Media.
creo
VOL 55, NO 4 / APRIL 2006 341w w w. j f p o n l i n e . c o m
Empiric therapy is appropriate in nonpregnant women with the triad of frequency, dysuria, and no vaginal symptoms
FAST TRACK
No single sign or symptom accurately predicted UTI. However, the triad of dysuria with frequency but without vaginal symptoms increased the probability of sig- nificant bacteriuria on culture from 50% to 96% (LR+ =24.6).1 In contrast, a 1999 review of 51 studies calculated that if both the nitrites and leukocyte esterase are posi- tive on urine dipstick testing, the LR+ is 4.2; if both are negative the LR– is 0.3.1,3
Since the probability of UTI for patients with the symptom triad is so high, dipstick urinalysis is unlikely to alter management regardless of whether nitrites and leukocyte esterase were both positive or negative (posttest probability=98%–99% and 80%, respectively). If urine dipstick or other office-based tests are not needed to make the diagnosis of uncomplicated UTI for a patient with the classic triad of symptoms, then telephone treatment based on symp- toms may be reasonable. Women who have recurrent UTIs (2 or more culture positive UTIs over the previous 12 months) can accurately self-diagnose subsequent UTIs based on symptoms (LR+ =4.0).4,5
A recent retrospective case series6 evalu- ated a telephone guideline for the empiric treatment of UTI for 4177 women in a California HMO. UTI criteria were ≤10 days of dysuria; frequency, urgency, pressure, or increased nocturia; or gross hematuria. Women were excluded if they had any one of a variety of contraindications (TABLE 1). Upper tract infection occurred in 21 patients (1.1%) within 60 days of telephone treatment, two thirds of which likely repre- sented treatment failures. This is similar to rates in control groups of other studies. Fourteen women (1.5%) received care for sexually transmitted diseases or other gyne- cologic conditions, primarily bacterial vaginitis, within 60 days of telephone treat- ment. Of note, 6% of the cohort were eld- erly, diabetic, taking glucocorticoids or early in pregnancy and are typically excluded from other studies. This higher-risk group did not have an increased incidence of either sepsis or pyelonephritis.6 No increase in adverse outcomes was seen in another study of a telephone treatment protocol.7
Several studies6–8 have noted that tele- phone treatment protocols increase the use of protocol-recommended antibiotics (eg, generally less expensive agents such as trimethoprim-sulfamethoxazole), which may help limit resistance to fluoro- quinolones. However, specific data are not available.
McIssac et al9 reviewed a cohort of 231 women presenting to family physi- cians’ offices with uncomplicated cystitis symptoms. Empiric therapy resulted in approximately 40% of women unneces- sarily receiving antibiotics. Treating only women with classic cystitis symptoms and pyuria would have decreased the unneces- sary use of antibiotics to 26.2%, but fewer women with confirmed cystitis would have received immediate antibiotics (66.4% vs 91.8%). They derived a clinical decision rule designed to balance false positives and false negatives. It recommends immediate antibiotic treatment if women have ≥2 of 4 signs or symptoms: dysuria, leukocyte esterase (greater than trace), positive nitrites, or blood (greater than trace) on dipstick (LR+ =2.29). Otherwise the rule recommends a culture to guide antibiotic
T A B L E 1
Vaginal discharge
Prolonged symptoms
Severe or intolerable flank, side, or abdominal pain
Inability to urinate for more than 4 hours
Body temperature higher than 38.1°C (100.5°F) with flank pain, chills, nausea, or abdominal pain
Pregnancy
Recent urologic surgery, procedure, or bladder catheterization; UTI within the last 6 weeks or frequent UTI (≥3 times) in the last 12 months
Any symptoms that warrant urgent office-based evaluation according to the clinician
Adapted from Vinson and Quesenberry, Arch Intern Med 2004.6
Contraindications to empiric antibiotics for urinary tract infection (telephone treatment)
CLINICAL INQUIRIES
creo
342 VOL 55, NO 4 / APRIL 2006 THE JOURNAL OF FAMILY PRACTICE
CLINICAL INQUIRIES
therapy. This decision rule would have reduced unnecessary antibiotic use by 27.5% while ensuring that more women with confirmed UTIs received immediate antibiotics (81.3%).
In 1999, Saint et al8 estimated savings of $367,000 for 147,000 women enrolled over 1 year after widespread guideline implementation. Two cost-effectiveness studies10,11 of office treatment concluded that empiric treatment without additional testing is the least costly option in this set- ting. However, a recent, comprehensive cost-effectiveness study11 concluded that if
a patient presents to an office, the margin- al cost of performing a pelvic examination and urine culture for women with a nega- tive dipstick was relatively low ($4 to $32 per symptom day avoided).
Recommendations from others
A 2002 Institute for Clinical Systems Improvement guideline12 advised offering telephone treatment of uncomplicated UTI for low-risk patients if preferred by both provider and patient.
R E F E R E N C E S
1. Bent S, Nallamothu BK, Simel DL, Fihn SD, Saint S. Does this woman have an acute uncomplicated uri- nary tract infection? JAMA 2002; 287: 2701–2710.
2. Hooton T, Scholes D, Stapleton AE, et al. A prospective study of asymptomatic bacteriuria in sexually active young women. N Engl J Med 2000; 343:992–997.
3. Hurlbut T, Littenberg B. The diagnostic accuracy of rapid dipstick tests to predict urinary tract infection. Am J Clin Pathol 1991; 96:582–588.
4. Gupta K, Hooton TM, Roberts PL, Stamm WE. Patient- initiated treatment of uncomplicated recurrent urinary tract infections in young women. Ann Intern Med 2001; 135:9–16.
5. Schaeffer AJ, Stuppy BA. Efficacy and safety of self- start therapy in women with recurrent urinary tract infections. J Urol 1999; 161:207–211.
6. Vinson DR, Quesenberry CP Jr. The safety of telephone management of presumed cystitis in women. Arch Intern Med 2004; 164:1026–1029.
7. Barry HC, Hickner J, Ebell MH, Ettenhofer T. A random- ized controlled trial of telephone management of sus- pected urinary tract infections in women. J Fam Pract 2001; 50:589–594.
8. Saint S, Scholes D, Fihn SD, Farrell RG, Stamm WE. The effectiveness of a clinical practice guideline for the management of presumed uncomplicated urinary tract infection in women. Am J Med 1999; 106:636–641.
9. McIsaac WJ, Low DE, Biringer A, Pimlott N, Evans M, Glazier R. The impact of empirical management of acute cystitis on unnecessary antibiotic use. Arch Intern Med 2002; 162:600–605.
10. Barry HC, Ebell MH, Hickner J. Evaluation of suspected urinary tract infection in ambulatory women: a cost- utility analysis of office-based strategies. J Fam Pract 1997; 44:49–60.
11. Rothberg MB, Wong JB. All dysuria is local. A cost- effectiveness model for designing site-specific man- agement algorithms. J Gen Intern Med 2004; 19(5 Pt 1): 433–443.
12. Uncomplicated urinary tract infection in women. Bloomington, Minn: Institute for Clinical Systems Improvement; July 2004. Available at guidelines.gov/ summary/summary.aspx?doc_id=5570. Accessed on March 7, 2006.
T A B L E 2
SUMMARY
Presenting to medical care 19.0 with possible UTI
Dysuria 1.5 0.5
Frequency 1.8 0.6
Hematuria 2.0 0.9
Recurrent UTI symptoms for 4.0 0.0 a woman with history of UTI
Vaginal discharge or irritation 0.2–0.3 2.7–3.1
Dysuria, frequency, 24.6 and absence of vaginal
discharge or irritation
+ Leukocytes* or + nitrate on urine dipstick analysis 4.2 0.3†
“UTI Rule”‡ 2.3
* Leukocyte greater than trace on dipstick † Leukocytes negative and nitrite negative ‡ “UTI Rule”—positive if 2 or more present: dysuria, + leukocytes, + nitrate,
+ heme (> trace)
LR, likelihood ratio; UTI, urinary tract infection. Adapted from Bent et al, JAMA 2002.1
Diagnosis of urinary tract infection
JFP_0406_CI.Final 3/16/06 2:56 PM Page 342
creo
E V I D E N C E - B A S E D A N S W E R
When are empiric antibiotics appropriate for urinary tract infection symptoms?
Evidence summary An evidence-based review1 found 5 high- quality studies on the diagnosis of acute uncomplicated UTI among women. (“Uncomplicated” was defined as normal urinary tract and no contributing medical problems, such as diabetes, neurogenic bladder, renal stones.) UTIs were defined as the presence of significant bacteriuria (≥104 to 105 colony-forming units) on culture. A patient presenting to a clinician with 1 or more UTI symptoms had approximately a 50% chance of having significant bacteriuria on culture.1 The
authors estimated the pretest probability of UTI as 5% from the incidence of asymp- tomatic bacteriuria among healthy women.1,2 This produced a LR+ of 19 sim- ply for presenting to a clinician with 1 or more UTI symptoms.1 The summary LRs for clinical signs and symptoms in the pre- diction of UTI after presentation to the office are found in TABLE 2. A history of a vaginal discharge or irritation has a LR– of 0.3, decreasing the probability of UTI for a patient presenting to the office from approximately 50% to 20%, so further testing would be indicated.1
Healthy, nonpregnant women presenting with the triad of frequency, dysuria, and no vaginal symptoms have about a 96% chance of having an urinary tract infection (UTI) (positive likelihood ratio [LR+]=24.6). Since no urinalysis result would substantially change the high likelihood of disease for these patients, empiric therapy is appropriate (strength of recommendation [SOR]: B).
A triage system based only on having 1 or more urinary symptoms is more sensitive but less specific: the chance of having a UTI drops to 50% (LR+ =19). While empiric therapy is still likely
to be appropriate, rates of false positives and inappropriate antibiotic use may rise (SOR: B).
Empiric treatment by telephone may also be considered (SOR: C). While no studies have specifically addressed the diagnostic value of UTI symptoms reported by phone, no increase in pyelonephritis or other adverse events has been seen with telephone treatment protocols. And while telephone treatment protocols can increase the use of guideline-recommended antibiotics and decrease costs, they may increase unneces- sary antibiotic use overall. Contraindications to empiric therapy are listed in TABLE 1.
Lauren DeAlleaume, MD, Elizabeth M. Tweed, BSN, MLIS University of Colorado Health Sciences Center, Denver
C L I N I C A L C O M M E N T A R Y
Telephone protocol for UTI reduces
unnecessary office visits and lab testing
We have 10 years of experience with a telephone treatment protocol we developed for uncomplicated UTI; it has since been adopted by the Institute for Clinical Systems Improvement (ICSI). The protocol reduces unnecessary office visits and lab testing. We believe the protocol actually increases our prescribing of preferred first-line antibiotics for UTI. While it is convenient
for our patients, its use has resulted in patients wanting to be treated over the phone even if they have “failed” the protocol. Overall, our patients are thankful we have a telephone protocol for uncomplicated UTI. We enjoy the use of a handful of other telephone protocols and hope to move toward web-based protocols in the future.
Robert Bonacci, MD Mayo Clinic, Rochester, Minn
C O N T I N U E D
CLINICAL INQUIRIES
Copyright® Dowden Health Media
For personal use only
For mass reproduction, content licensing and permissions contact Dowden Health Media.
creo
VOL 55, NO 4 / APRIL 2006 341w w w. j f p o n l i n e . c o m
Empiric therapy is appropriate in nonpregnant women with the triad of frequency, dysuria, and no vaginal symptoms
FAST TRACK
No single sign or symptom accurately predicted UTI. However, the triad of dysuria with frequency but without vaginal symptoms increased the probability of sig- nificant bacteriuria on culture from 50% to 96% (LR+ =24.6).1 In contrast, a 1999 review of 51 studies calculated that if both the nitrites and leukocyte esterase are posi- tive on urine dipstick testing, the LR+ is 4.2; if both are negative the LR– is 0.3.1,3
Since the probability of UTI for patients with the symptom triad is so high, dipstick urinalysis is unlikely to alter management regardless of whether nitrites and leukocyte esterase were both positive or negative (posttest probability=98%–99% and 80%, respectively). If urine dipstick or other office-based tests are not needed to make the diagnosis of uncomplicated UTI for a patient with the classic triad of symptoms, then telephone treatment based on symp- toms may be reasonable. Women who have recurrent UTIs (2 or more culture positive UTIs over the previous 12 months) can accurately self-diagnose subsequent UTIs based on symptoms (LR+ =4.0).4,5
A recent retrospective case series6 evalu- ated a telephone guideline for the empiric treatment of UTI for 4177 women in a California HMO. UTI criteria were ≤10 days of dysuria; frequency, urgency, pressure, or increased nocturia; or gross hematuria. Women were excluded if they had any one of a variety of contraindications (TABLE 1). Upper tract infection occurred in 21 patients (1.1%) within 60 days of telephone treatment, two thirds of which likely repre- sented treatment failures. This is similar to rates in control groups of other studies. Fourteen women (1.5%) received care for sexually transmitted diseases or other gyne- cologic conditions, primarily bacterial vaginitis, within 60 days of telephone treat- ment. Of note, 6% of the cohort were eld- erly, diabetic, taking glucocorticoids or early in pregnancy and are typically excluded from other studies. This higher-risk group did not have an increased incidence of either sepsis or pyelonephritis.6 No increase in adverse outcomes was seen in another study of a telephone treatment protocol.7
Several studies6–8 have noted that tele- phone treatment protocols increase the use of protocol-recommended antibiotics (eg, generally less expensive agents such as trimethoprim-sulfamethoxazole), which may help limit resistance to fluoro- quinolones. However, specific data are not available.
McIssac et al9 reviewed a cohort of 231 women presenting to family physi- cians’ offices with uncomplicated cystitis symptoms. Empiric therapy resulted in approximately 40% of women unneces- sarily receiving antibiotics. Treating only women with classic cystitis symptoms and pyuria would have decreased the unneces- sary use of antibiotics to 26.2%, but fewer women with confirmed cystitis would have received immediate antibiotics (66.4% vs 91.8%). They derived a clinical decision rule designed to balance false positives and false negatives. It recommends immediate antibiotic treatment if women have ≥2 of 4 signs or symptoms: dysuria, leukocyte esterase (greater than trace), positive nitrites, or blood (greater than trace) on dipstick (LR+ =2.29). Otherwise the rule recommends a culture to guide antibiotic
T A B L E 1
Vaginal discharge
Prolonged symptoms
Severe or intolerable flank, side, or abdominal pain
Inability to urinate for more than 4 hours
Body temperature higher than 38.1°C (100.5°F) with flank pain, chills, nausea, or abdominal pain
Pregnancy
Recent urologic surgery, procedure, or bladder catheterization; UTI within the last 6 weeks or frequent UTI (≥3 times) in the last 12 months
Any symptoms that warrant urgent office-based evaluation according to the clinician
Adapted from Vinson and Quesenberry, Arch Intern Med 2004.6
Contraindications to empiric antibiotics for urinary tract infection (telephone treatment)
CLINICAL INQUIRIES
creo
342 VOL 55, NO 4 / APRIL 2006 THE JOURNAL OF FAMILY PRACTICE
CLINICAL INQUIRIES
therapy. This decision rule would have reduced unnecessary antibiotic use by 27.5% while ensuring that more women with confirmed UTIs received immediate antibiotics (81.3%).
In 1999, Saint et al8 estimated savings of $367,000 for 147,000 women enrolled over 1 year after widespread guideline implementation. Two cost-effectiveness studies10,11 of office treatment concluded that empiric treatment without additional testing is the least costly option in this set- ting. However, a recent, comprehensive cost-effectiveness study11 concluded that if
a patient presents to an office, the margin- al cost of performing a pelvic examination and urine culture for women with a nega- tive dipstick was relatively low ($4 to $32 per symptom day avoided).
Recommendations from others
A 2002 Institute for Clinical Systems Improvement guideline12 advised offering telephone treatment of uncomplicated UTI for low-risk patients if preferred by both provider and patient.
R E F E R E N C E S
1. Bent S, Nallamothu BK, Simel DL, Fihn SD, Saint S. Does this woman have an acute uncomplicated uri- nary tract infection? JAMA 2002; 287: 2701–2710.
2. Hooton T, Scholes D, Stapleton AE, et al. A prospective study of asymptomatic bacteriuria in sexually active young women. N Engl J Med 2000; 343:992–997.
3. Hurlbut T, Littenberg B. The diagnostic accuracy of rapid dipstick tests to predict urinary tract infection. Am J Clin Pathol 1991; 96:582–588.
4. Gupta K, Hooton TM, Roberts PL, Stamm WE. Patient- initiated treatment of uncomplicated recurrent urinary tract infections in young women. Ann Intern Med 2001; 135:9–16.
5. Schaeffer AJ, Stuppy BA. Efficacy and safety of self- start therapy in women with recurrent urinary tract infections. J Urol 1999; 161:207–211.
6. Vinson DR, Quesenberry CP Jr. The safety of telephone management of presumed cystitis in women. Arch Intern Med 2004; 164:1026–1029.
7. Barry HC, Hickner J, Ebell MH, Ettenhofer T. A random- ized controlled trial of telephone management of sus- pected urinary tract infections in women. J Fam Pract 2001; 50:589–594.
8. Saint S, Scholes D, Fihn SD, Farrell RG, Stamm WE. The effectiveness of a clinical practice guideline for the management of presumed uncomplicated urinary tract infection in women. Am J Med 1999; 106:636–641.
9. McIsaac WJ, Low DE, Biringer A, Pimlott N, Evans M, Glazier R. The impact of empirical management of acute cystitis on unnecessary antibiotic use. Arch Intern Med 2002; 162:600–605.
10. Barry HC, Ebell MH, Hickner J. Evaluation of suspected urinary tract infection in ambulatory women: a cost- utility analysis of office-based strategies. J Fam Pract 1997; 44:49–60.
11. Rothberg MB, Wong JB. All dysuria is local. A cost- effectiveness model for designing site-specific man- agement algorithms. J Gen Intern Med 2004; 19(5 Pt 1): 433–443.
12. Uncomplicated urinary tract infection in women. Bloomington, Minn: Institute for Clinical Systems Improvement; July 2004. Available at guidelines.gov/ summary/summary.aspx?doc_id=5570. Accessed on March 7, 2006.
T A B L E 2
SUMMARY
Presenting to medical care 19.0 with possible UTI
Dysuria 1.5 0.5
Frequency 1.8 0.6
Hematuria 2.0 0.9
Recurrent UTI symptoms for 4.0 0.0 a woman with history of UTI
Vaginal discharge or irritation 0.2–0.3 2.7–3.1
Dysuria, frequency, 24.6 and absence of vaginal
discharge or irritation
+ Leukocytes* or + nitrate on urine dipstick analysis 4.2 0.3†
“UTI Rule”‡ 2.3
* Leukocyte greater than trace on dipstick † Leukocytes negative and nitrite negative ‡ “UTI Rule”—positive if 2 or more present: dysuria, + leukocytes, + nitrate,
+ heme (> trace)
LR, likelihood ratio; UTI, urinary tract infection. Adapted from Bent et al, JAMA 2002.1
Diagnosis of urinary tract infection
JFP_0406_CI.Final 3/16/06 2:56 PM Page 342
creo
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